The State of Connecticut
Department of Economic and Community Development
Connecticut Development Authority
Pre-Application
Pre-Application Instructions
General Description
This request for Business Assistance is a brief outline to enable the DECD/CDA to determine, on a preliminary basis, the suitability and eligibility of the business to apply for financial assistance. A current business plan should be included with the Request for Business Assistance Application (consult with your Regional Manager if assistance is needed). The business plan should include a complete description of the firm, its products and services, the project and an explanation of the use of DECD/CDA funds. If the Pre-Application is approved, you will be asked for additional information to complete a final application. All information accompanying this Application is confidential and exempt from the Freedom of Information Act.
1.Business Name: List the full legal name of the applicant for financial assistance.
2.Address: Mailing address where correspondence should be sent. If different from the applicant location, so indicate.
3.Contact Person: If appropriate, include title.
4.Borrower: If other than the Business; list the individual(s), partnership or holding company.
5.Project Location: Give the location where financing will be used. The municipality is the jurisdiction to whom property taxes are paid.
6.Nature of Business: Give a complete, but concise, description of what the business does (e.g. restaurant, machine tool, etc.) Do not forget the Federal Employer ID # and SIC Code.
7.Ownership: If not practical to list every business owner, include owners holding 10% or more of the business. If ownership of the borrower is different from the business, please list on a separate sheet the owners of the borrower. Minority or woman ownership must be 51% to be considered for this status. (“Minority” includes a variety of categories such as racial, ethnic, gender and disability status. Check with DECD/CDA staff to be sure.)
- Assistance Requested:
- Amount of Financing Requested: Specify amount and nature of assistance.
- Service(s) Requested: Identify type(s) of service requested.
9. Gross Sales/Receipts: Gross/Sales receipts of the business during the last calendar or fiscal year.
10. Employment: Projected employment is the anticipated number of employees working at the project within 3-5 years.
11.Project Costs: Give best estimate
12.Source of Funds: In many cases, the DECD/CDA will not be the primary source of funds. For some projects, a match will be required by law. Be sure to identify other sources of funds tocomplete theproject. Total sources of funds should equal total project costs.
13.Project Description: Describe the project for which funding is being requested (i.e., type of equipment to be purchased, nature of inventory and uses for working capital). For a building, include address, acres of land, building's square feet, and size of any building addition. List any tenants. If project involves refinancing, describe who will be refinanced and the purpose for the loan.
19.Required documents: (for pre-application phase):
A. Business Plan: Include a current copy of the firm's business plan.
B. Business Financial Statements: If available, CPA prepared financial statements for the most recent three years with 5 year projections. Otherwise, federal tax returns.
C. Cash Flow: Please include, as a part of the financial statements, a summary of cash flow covering prior year's operations.
D. Payroll, Sales, Corporate Taxes paid to Connecticut (past 3 years and projected for 5 years).
E. Personal financial statements of owners of 10% or more of the company.
F. Schedule of related affiliated companies.
G. If the project involves the purchase of a business, please provide the following:
I.Purchase Agreement or memorandum between the parties.
II. Current balance sheet of business being acquired.
III.Appraisal, or estimate of value, of seller's real estate and equipment.
21. Conventional Financing: Outline the amount and terms of of any funds from conventional sources that are available to fund all, or a portion of the project. If applicable, indicate reasons for denial.
24.Public Disclosure: The DECD/CDA is required by law to include in its final approval consideration the extent to which the applicant has included community and employee participation, unless this question is answered "Yes", and an explanation is provided.
Pre-Application
(Please refer to the instructions on the previous page.)
1. / Business Name:2. / Address:
Zip Code:
3. / Contact Person
Telephone: / Fax:
4. / Borrower(s)
5. / Project Location /
Municipality:
6. / Nature of Business: / SIC CodeManufacturer / Retailer / Wholesaler
Service Company / Construction / Finance, Insurance or Real Estate
Other (specify)
Type of Product of Service:
Federal Employer ID# / State Tax Registration #
7. / Ownership
Name / Title / % of Ownership / SS#
Minority owned / Woman owned (must be 51% minority or woman to qualify)
8. /
Assistance Requested
A. / Amount of Financial Assistance Requested: / $B. / Service(s) Requested:
9. /
Gross Sales/Receipt
Total Sales/Receipts / $ / Approximate % Sales in CTApproximate % sales outside of CT / Approximate % sales outside of US
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10. /Connecticut Employment
Current Connecticut Employment
/Project Related Connecticut Employment Employment Employment
Number of Jobs / Minority / Retained / To be CreatedFull-Time
Part-Time
Total
11. / Project Costs
Machinery and Equipment / $ / Inventory / $
Working Capital / $ / Leasehold Improvements / $
Purchase of Land / $ / Purchase of Existing Building / $
Renovations/Construction / $ / Refinance of Existing Debt / $
Relocation / $ / Other / $
TOTAL PROJECT COST
/ $12. / Source of Funds
Amount of DECD Funding / $ / Equity from owners/partners / $
Amount of CDA Funding / $ / Bank Loan / $
Funds from the Business / $ / Other / $
TOTAL SOURCES OF FUNDING
/ $13. / Project Description (attach additional sheet if necessary)
14. / Form of Organization
Private for Profit / Municipality
Non-Profit / Other (please explain)
15. / Form of Ownership
Corporation / Partnership
Proprietorship / Other (please explain)
Sub-Chapter "S" corp.
Date Acquired/Established:
16. / Unpaid Taxes (List any below)
Type / Amount / Past due / Payment Terms
Federal
State
Local
17. / Are there outstanding, pending or anticipated claims or litigation against your company?
Yes (If "yes", please attach explanation) / No
18. / Have you ever personally declared bankruptcy or been an officer of a company or organization where bankruptcy has been declared?
Yes (If "yes", please attach explanation) / No
19. / Required Documents (please refer to the instruction page)
A.Business Plan
B.Business Financial statements (include notes and projections)
C.Cash Flow Summary for prior year
D.Payroll, Sales, Corporate Taxes Paid to CT (past 3 years, projected for 5 years)
E.Personal financial statement(s) (owners of 10% or more of company)
F.Schedule of related affiliated companies
G.Information regarding a business acquisition
20. / Have you received prior State financing?Yes / DECD / CDA / CII / Amount / $ / Program / Date
No
21. / Conventional Financing
Please describe, on an additional sheet, what steps, if any, you have taken to obtain financing from conventional sources. Please outline the amount(s) and term(s) of the financing.
22. / Environmental Compliance
Do you have any outstanding orders or citations from either the Connecticut Department of Environmental Protection or federal Environmental Protection Agency? If yes, please describe on an additional sheet and give the name, address and telephone number of the individual handling your case at the respective agency.
23. / OSHA Compliance
Do you have any outstanding orders from the federal Occupational Safety and Health Administration? If yes, please describe on an additional sheet and give the name, address and telephone number of the individual handling your case.
24. / Public Disclosure
Will informing the municipality and employee representatives of the proposed request for financial assistance prior to DECD's final approval be considered a disclosure of confidential or proprietary information, or trade secret?
/ No / Yes (If "yes" please attach explanation)
Certification by Applicant
It is hereby represented by the undersigned as an inducement to the Department of Economic and Community Development and/or the Connecticut Development Authority to consider the financial assistance requested herein, that to the best of my knowledge and belief no information or data contained in the pre-application or in the attachments are in any way false or incorrect and that no material information has been omitted, including the financial statements. The undersigned agrees that banks, credit agencies, the Connecticut Department of Labor, the Connecticut Department of Revenue Services, the Connecticut Department Environmental Protection, and other references are hereby authorized now, or anytime in the future, to give the Department of Economic and Community Development any and all information in connection with matters referred in this pre-application, including information concerning the payment of taxes by the applicant. In addition, the undersigned agrees that any funds that may be provided pursuant to this pre-application will be utilized exclusively for the purposes represented in this pre-application, as may be amended.
Signature:Title:Date
Please be sure to include the additional attachments required.
Return to:
C/O
DEPARTMENT OF ECONOMIC AND COMMUNITY DEVELOPMENT
505 Hudson Street
Hartford, CT 06106
Phone (860) 270-8000
Fax (860) 270-8055
Revised 7/01
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